I make reference why we have a nursing shortage. Clinical documentation specialists are nurses who have been trained to audit physician documentation in order to remind them to accurately document resource utilization. Let's call it what it is. It's all part of the big game between the Medicare National Bank (MNB), and everyone trying to increase their portion of the pot. It is a natural response to the system, created by the system.

The MNB created the system of games and hoops which add untold billions to the cost of delivering care. I am known in my group is being well in tune with the ins and outs of medical billing and coding. I have spent hours and hours and hours learning the rules of the Medicare playing field. I know the rules very well.

I know what to write and I know exactly how to document because if it wasn't documented it didn't exist. Right? I know a lot about what to document so the hospital gets paid. You see, if the hospital earns more money because I code better, my value to the hospital just went up.

Why do I write words like:

EKG tracing personally reviewed, or CXR film personally reviewed, or reviewed case with nursing staff, or meds reviewed, or document 3 vitals, or list the status of 4 problems or document the status of 3 chronic medical problems, or list 2 ROS and on and on and on. These are all requirements necessary to get paid and not be accused of fraud.

I know them front and back. They are ingrained in my brain. These are the words the MNB says I must write to get paid. Do I do that 15 times a day because the patient cares? No I do that 15 times a day so I get accused of fraud. I create value to others who reap the benefit of my value and make my services worth more. It is the American way.

So here comes the clinical documentation specialist RN. Here's an example of two patients being audited for documentation of resource utilization.

Patient one has documented community acquired pneumonia with hypoxemia. The clinical documentation specialist recommends instead to define the pneumonia into the following categories: aspiration, bacterial, viral or fungal. Patient two has documented influenza pneumonia with hypoxemia. The clinical documentation specialist recommends instead to defined the pneumonia into the following categories: aspiration, bacterial, viral or fungal.

Any hospitalist would probably be confused by now. Influenza is a virus but coders are not allowed to infer that influenza is a virus. Therefore the additional resource utilization provided for flu related pneumonia would not be captured. My training affords me a false sense of expectation for common sense. What is common sense to me is far from common sense to others, even other highly educated medical professionals. Documenting community acquired pneumonia vs nursing home acquired vs hospital acquired pneumonia has absolutely zero affect on how much the hospital collects in DRG payments. Even though these clinical descriptors help physicians defined therapy options and treatment goals.

Unfortunately, hospitalists must document pneumonia by bacteria type to increase payment for the hospital, which will make my value to the hospital go up compared to my peers. But hospitalists should also be documenting community acquired vs nursing home acquired vs VAP vs hospital acquired vs ICU pneumonia....etc.... for defining therapies and goals. In addition, hospitalists should also be documenting comorbidities and complications due to the 2008 introduction of severity adjusted DRG payments (CC and MCC)

The replacement of the old DRG (CMS-DRG) system, which was relatively stable since its 1983 inception, means that hospitals and, in particular, physicians and HIM, coding, and quality improvement departments must carefully work within the new system to ensure accurate reimbursement.

Effective for discharges after October 1, 2007, the new severity-based DRG System applies. The rule creates 745 new severity-adjusted diagnosis-related groups to replace the current 538 DRGs. The 745 Medicare severity-based DRGs (MS-DRGs) are divided into three severity levels: MCC, CC, and Non-CC. The familiar complication and comorbidity (CC) classification has been expanded to include CCs and major CCs (MCCs), which are conditions that require double the additional resources of a normal CC

The bad news is that CMS is implementing a corresponding 4.8% payment cut over a 3-year period, including a 1.2% reduction for FY 2008 and proposed 1.8% reductions for FYs 2009 and 2010. This reduction is to offset the improved documentation and coding (and therefore payment) CMS believes providers will adopt, based on past data. CMS has stated that substantial evidence supports the conclusion that the adoption of new payment systems leads to an increase in aggregate payments without any corresponding growth in actual patient severity.

Let me sum up the current state of medicine in 2008, Medicare style: 66 yo independent female with 3 day hx of progressive SOB, productive cough, fever. Chest xray shows left lower lobe pneumonia. ABG in the ER shows a pO2 o 47 on RA. Patient requires admission for antibiotics and close monitoring for decompensation.

In a Utopia of ultimate efficiency, how should this patient be managed?

Quinolone or Cefotaxime/Ceftriaxone +Zithromax should suffice. Put her on some oxygen, prn inhalers and watch her closely in the hospital for decompensation. This is effective, cheap as cheap can be, medical care. It is efficient and adequate for good outcomes. And these actions can take just minutes.

What is the reality of care in the 2008 Medicare style?

Well, it starts in the ER.

1) The ritualistic drawing of the blood cultures, followed by the ritualistic vein light for IV access and the giving of the 750mg of Levaquin. The ER doc then calls the hospitalist who automatically asks the following: "Did you draw blood cultures? Did you give the first dose of antibiotics?"---these are both quality indicators according to the MNB

2) You see, how doctors get paid, I must do a 4 point HPI medical history including past medical, allergy, medication, family, social history. I must do a 12 point review of systems. I must do a complete H&P examination of all organ systems. I must document clearly the level of decision making between mild, moderate and high risk, based on a point system. Anything less than 100% of this stated documentation drops me from the highest admission code 99223 to the lowest admission code 99221.

So here's my note:

HPI: 66 yo F 3 day Hx of cough, productive, congestion, fever. No specific pain, symptoms are constant. Nothing makes it better or worse. No other associated signs or symptoms.

PMH

Allergies: none

Illnesses: none

Meds: none

FH: no CAD

SH: nonsmoker

ROS: A 12 point review of systems was reviewed. In the abscence of the above stated finding s there were no other pertinent positives or negatives.

PE:

General:...NAD

Vitals: 147/85 * 110* 101.4 86% on RA

HENT: Normal

Eyes: Normal

Neck: Normal

CV Tachy, otherwise normal

Pulmonary: lll crackles, no wheeze

Abd: Normal

Skin: nomral

Vasc: normal

MS: normal

Neuro: Normal

Psych: Normal

Data. WBC 17K Cr 1.1 pH 7.45, pCO2 33, pO2 47

EKG, NSR w/o ST/TWC's tachy

CXR film reviewed c/w LLL pneumonia

1) Community Acquired Pneumonia

2) Tachycardia

3) Leukocytosis

4) Hypoxemia

Plans.. Admit. IV antibiotics.

This is skeleton note that will get me the highest level of reimbursement for a 99223 admission. It has every component needed to achieve the highest level of payment. But it doesn't end there. Not only should I rightfully be paid for my services rendered I also must document appropriately so that 1) the hospital gets paid at a maximum rate so my value to them increases and 2) I must document severity of illness adequately so my actual mortality is not higher than my expected mortality. So what do I need to change in my impression and plan?

Lets go back and look at that again. For pneumonia, a higher DRG is achieved by documenting the specific type of bacteria. Now, the government says I need to draw blood cultures. It's a very rare day, if ever, that a blood cultures change my management. Community acquired pneumonia is appropriately treated with quinolones or ceph+mycin.

But to get the hospital to be paid more, I order a sputum culture, with the hope that a bacteria is cultured. The most common organism, Streptococcus pneumonia, does not pay more. So I may not get lucky with a Legionella, or a gram-negative to boost the DRG payment. The DRG for simple pneumonia pays less than the DRG for pseudomonas pneumonia.

Lets also look at the complicating factors. The tachycardia, leukocytosis and fever would qualify this patient as having systemic inflammatory response system. I don't know if that's considered a complicating factor (CC or a MCC) from the MNB. Lets assume it is. Lets also assume that hypoxemia is considered a complicating (CC) factor too. I have to be sure to document both as complicating factors to increase the severity of illness which will have the double effect of increasing reimbursement to the hospital and make the expected mortality rate of the patient higher, there by making my actual mortality rate lower if the patient lives.

And to top things off, the most important aspect of the pneumonia, the fact that it comes from an ambulatory female and is known as community acquired pneumonia has no bearing on the financial payment to the hospital or to my expected mortality. It is just used for statistical purposes.

So what am I left with? The good physician who plays the game, maximized hospital payment, skews their expected mortality in their favor and accurately portrays the rational for antibiotic coverage choices would have to document the following:

Community acquired pneumonia, streptococcus pneumonia, with associated SIRS and hypoxemia.

Documenting this will achieve all of the above desired effects. How does the patient fare? The patient couldn't doesn't know and doesn't care about all this mind boggling nonsense. But it adds hours and hours and hours of inefficiencies to the delivery of health care. All hospitals in this country are hiring coders for coders and doing chart audits on doctors to make sure they write what they need to to get paid.

It is all a giant game that leaves the patient out of the equation. They got their appropriate antibiotics and that's really all that matters. It's quite funny and sad at the same time. At the end of the day, I manage patients, while the whole health care world around me tries to manage me. It seems to me that physicians are best managed by other local physicians. If you area terrible physicians, you will not get any referrals. A physician knows who has the necessary skills and who doesn't better than anyone else. Why? Because it's difficult to for physicians to pull the wool over another physician's eyes. Our training affords us a special radar by nature of our training. That radar can see more insight in a day than any EMR platform or PQRI program can gather in a lifetime.

17
Outbursts:

Thank you,thank you ,thank you for this post. From time to time when I complain to my significant other that I have little to do and have lost my identity since I have retired she tells me how lucky I am. Your narrative proved to me I am really lucky to be retired and do not have to go to the Kafka world that the doc who cares for patients in the hospital finds himself.

try doing all that stuff with no emr. it's all bs that attempts to force people to buy an emr.why doesn't cms require the coders to be able to read the charts in a reasonable fashion? no wonder their administrative costs are contained--they just force it on the clinics and hospitals.

WONDERFUL post. Seriously, I think you should put it in letter form and send it to your congressman, or to Pete Stark, or to Secretary Leavitt's blog, or something. You spent too much time documenting the bullshit documentation to let this go to waste.And yes, it's scary, isn't it? about what nurses don't know. Influenza is a virus. Hmmm.....

A 12 point review of systems was reviewed. In the abscence of the above stated findings there were no other pertinent positives or negatives

I work in a teaching hospital.I see statements such as this all the time in H&Ps by the housestaff. I think it is bulls**t and that they did not do a complete ROS.Perhaps in your fictional patient with no PMH the ROS may be negative. But in my experience, most hosptialized patients will have some pertinent negatives or positives if you really ask the questions.I understand the need to document for coding, but think that if a ROS was truly done, then the specific negatives or positives should be listed.CardioNP

"1) I'm documenting pneumonia by bacteria type to increase payment for the hospital, which will make my value to the hospital go up compared to my peers, And a higher value service commands a higher premium. (like buying an iMac)"

Really? If you know as much about coding as you purport, you'd know that specific diagnoses have higher morbidity and mortality rates and that those rates are gleaned from the assigned ICD-9 codes. Where do you think the research numbers come from? Air?

Anonymous said...

"try doing all that stuff with no emr. it's all bs that attempts to force people to buy an emr. why doesn't cms require the coders to be able to read the charts in a reasonable fashion? no wonder their administrative costs are contained--they just force it on the clinics and hospitals. And yes, it's scary, isn't it? about what nurses don't know. Influenza is a virus. Hmmm....."

One: if coders could only READ your writing (those notes more than 2 words long)....

Two: No wonder there's a nursing shortage with attitudes like yours out there. When the nurses disappear are YOU going to provide the 24-hour care for demented patients climbing out of bed and replacing those IVs and foleys for the 10th time?

Anonomous: So you do stuff that doesn't need to be done so that you can charge for it to make as much money as possible? How do you feel about your ethics? Why should anyone trust you? Your patients?

Response: Bravo! Just who are you kidding? You have more posts about making money (your own) than about the rewards of taking care of people; not patients: also known as: "the means to the money". Thank God nurses don't have your attitude. Remember, some day you'll be old and sick (no matter how much you jog now) and someone will have to wipe your butt, and they won't be seeing dollar signs when they do THEIR assessments!

Thanks for the insight for a very difficult situation with Medicare and hospitals. I left the hospital due to the very things you describe . I will never go back and most FPs here left too. keep up your documentation of all the garbage we are forced to do . xcmd

I thoroughly enjoyed your post, I have worked in hospice care, I was an EMT and now I am a coder. Everybody has a different point of view but quite frankly if the patient is still treated for the illness and tested than the patient care remains with the physician. However the payment being the topic, since every business and it is a business people needs to make money, their will always be red tape. Insurances will pay for a patient with jaw pain to be seen at their PCP but not for specific TMJ as it is considered dental etc.... There are many cases of this and they happen and we fight them and change and adapt everyday. You as a business person are doing your best as a provider for the business. You as a physician are doing your best for the patient, this is your curse and I wish you luck because truthfully it is all a bunch of BS that just provides higher patient bills, frustrated physicians, RN's, CMA's, MA's and patients etc..

Blood cultures are not required for all patients admitted with pneumonia, only patients being admitted to the ICU. Which is "duh" necessary...if your patient is being admitted to the ICU then they are likely sick enough to have sepsis. At least you get a lead on giving the best care for your patient. The quality measure for the Core Measure for pneumonia and blood cultures states that if blood cultures are ordered, they must be drawn prior to the initial administration of the first antibiotic...another "duh!" Come on Docs...give the best care possible. I was previously a Quality Specialist RN and am now a Clinical Documentation Specialist...I feel as though I am babysitting some of the physicians, literally...don't be afraid to say "bacteremia" rather than "positive blood cultures..." Don't be afraid to say "sepsis" when your patient is really ill and meets criteria...however, don't just say sepsis because you are billing for a higher level of service from your office...RAC will get you eventually because I am telling my coders NOT to code sepsis when the criteria and/or treatment are not present!!!!